POPULATION
HEALTH AND THE
CLINICAL NURSE
LEADER
This session supported by AACN/CDC
Academic Partnership Program
U.S. HEALTHCARE AND THE WORLD
Are we making any progress?
http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
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GOALS FOR U.S. HEALTHCARE
Institute for Health Improvement. The triple aim for U.S. Healthcare.
http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx
THE PARADIGM SHIFT IN HEALTHCARE
Population health is emerging as a central outcome for the healthcare
system to attempt to change the paradigm and improve our system
performance.
Population health is not public health – it is not directly tied to
governmental health departments
Population health includes the healthcare delivery system which was
historically seen as separate from governmental public health.
(Stoto, M., (2013). Population health in the affordable care act era.
Academy Health pp1-6)
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INSTITUTE OF MEDICINE PRIMARY CARE
AND PUBLIC HEALTH
There is a need for integration between primary care and public health to achieve
the goals of population health. What is integration?
ACA AND POPULATION HEALTH
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THE NATURE OF DEMAND FOR RNS
ACUTE CARE NURSING IS CHANGING
AND THE ROLE OF NURSES IS CHANGING
Our speakers today are on the front-lines of the change.
The role of nurses in acute care is changing and new skills are needed
The CNL role is emerging as an essential part of this change
Expansion of the CNL into ambulatory care, public health, and accountable care
organizations is inevitable.
We hope our presentations will provide you with validation, new ideas, and new ways
to think about the CNL role in improving our healthcare system.
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CNL Role and Future In
Population Wellness
Objectives
• State of Healthcare and directions toward
population management
• How will reimbursements impact acute care
• Define CNL role in acute care support and
address continuum of care opportunities
• Expansion of CNL roles in new areas of care:
chronic disease management, wellness,
prevention and population health
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Our flagship facility, Meritus Medical Center is an acute care hospital with 276
beds and the most advanced technologies available and is staffed by more than
300 physicians in 30 specialties. Meritus Medical Center opened on December
11, 2010, replacing Washington County Hospital.
Who we serve
Western MD, Eastern panhandle of WV and southern PA.
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Reform Objectives
Opportunity
for Maryland
to be a
NATIONAL
LEADER
CHANGE
BUILD
the way we
pay for and
provide
health care
on the great
system we have
and make it
even better:
• More affordable
in health care
• Safer
• A healthier
Maryland
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History
But 40-year-old waiver “test” was out of date
OLD
NEW
Inpatient care
All hospital care
Medicare only
All payers
Cost of care per
hospital stay
Cost of care per
person overall
14 14
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Lower Cost
Annual
hospital
SPENDING
CAP −
3.58% per
capita
Medicare
SAVINGS
TARGET −
$330 million
over 5 years
GROWTH in
Maryland
spending
per capita
cannot
exceed
nation
15 15
All-Payor Per Capita Target:
3.58%
GROSS HOSPITAL REVENUE PER CAPITA GROWTH
TARGET
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16
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New Incentives
Changes how hospitals are paid to
reward the right things
•Success under the new rules requires
–
–
–
–
cost reduction
care for patients in the community
care in lower cost setting
reduce unnecessary care
• The key: population health management
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10
Reduce Potentially
Preventable Complications by 30%
POTENTIALLY PREVENTABLE COMPLICATIONS
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Population Health Management
Changes How Providers Think
•
•
•
•
•
Do more to earn more Rewards for efficiency and quality
Care for an individual patient Care for an entire population
Acute care Ambulatory care Community care
Competition Collaboration
Hospital care Health care
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Population Health Management
Requires Different Role for Hospitals
•
•
•
•
•
Supply proactive, preventive and chronic care to all
During and between encounters
Regular contact with patients
Support patient efforts to manage their health
Manage high risk patients to prevent from worsening
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Health is About More Than Clinical Care
Health is driven by multiple factors that are intricately linked –
of which medical care is one component.
Personal Behaviors
40%
Family History and
Genetics
30%
Environmental
and Social
Factors
20%
10%
Medical
Care
Source: Determinants of Health and Their Contribution to Premature Death, JAMA 1993
Population Health
Meritus Health is committed to improving the health
of our community through initiatives like:
– Community based health education
– Outpatient and retail services
– THP-Meritus ACO Program
– School Health Program
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• Established in January 2013
• One of the first ACO’s in Maryland
• Dedicated to a patient-centered approach to
population health
• Improves outcomes and patient experience through
cost- effective delivery of coordinated care
• Meritus Health employees staff the health rooms of all 47
Washington County Public Schools through a collaborative
contract with the school system.
• On average, our healthcare providers see 1000 students each
day in the school health rooms.
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• Onsite “doctor’s office” at two school
locations
• Complement the Meritus Health
School Health program.
• Increase children’s access to health
care
• Improve their chances of educational success by increasing their
time spent in school.
• Provides evaluation and treatment for illness and injury, health,
nutrition and referrals to mental health services.
• Challenges of changing workforce requirements:
• Total Payment Revenue (TPR) and Global Budget
Reimbursement (GBR) models
– Shrinking In-Patient Services – Hospital – RN training
– Increase demand for community intervention –
Nursing and care coordination - Navigation
– Advance Practice role demand in primary care,
school based centers, ACO – medical home models –
physician adaptation to changes
– BSN role requirement
– Advance nursing degree demand for DNP, Ph.D.
researchers and MPH type roles hard to fill
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• Challenges continued
– VBP – Core Measures, Pt. Experience, Harm
• Readmission
• Skilled Nursing Facilities
• LTC – Western Maryland Hospital Center
– Leaders of Population Health
• Models of Care
–
–
–
–
Navigators
BH imbedded in practices – what type of provider
Rehab – no longer hospital centric
Local and State health department role - diminishing
• Skill Sets for current workforce demand is currently not
commonly available.
Skill Sets
• Customer focus – centric across the
continuum
• Research toward population health services,
interventions lacking
• Coordination, education and health
maintenance leaders in all aspects of
community health
• CNL embedded in primary care for chronic
disease management coordination
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New Paradigm
• Our care responsibilities for health systems,
care providers, nurses and CNL does not end;
– WHEN THE PATIENT LEAVES OUR FRONT DOOR
• OUR NEW EVALUATION TOOLS ARE MOVING:
– Toward care effectiveness on a pop scale
• total cost, utilization of resources and wellness goals for
individuals, community and populations
Opportunity for CNL
• EBP improvements in efficiency, safety and
utilization across the continuum
• Re-design CNL role outside acute care
– Schools
– LTC support, intervention and management
– Community education, leadership and advocacy
– Wellness beginning with employee and expanding
– Health interventions for chronic disease
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A Public Health CNL
DANA SMOTHERS BSN, MS, RN, CNL
Yamhill County
county total population: 101,000
Source of RH visits
Payment 2013
Title X
43.6%
OHP
19.0%
CCare
30.6%
Private
Total
6.6%
100.0%
RH
Source of visits
Payment 2014
Reproductive Health (RH) clinic
race/ethnicity:
Hispanic or Latino - 49.0%
White, non-hispanic - 47.3%
Title X
38.5%
OHP
30.8%
CCare
21.6%
Private
Total
8.9%
100.0%
U.S. Census Bureau, 2010; 2013, County Agency Data Review, Oregon Reproductive Health Program
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Oregon Public Health Task
Force & CCO
• 501(c)3, grass-roots, communitybased
• CCO Incentives (17) & State
Performance Measures
“effective contraceptive use among
women at risk of
unintended
pregnancy”
Michael Tynan, Office of the State Public Health Director, Oregon Health Authority.
Findings from the Future of Public Health Task
Force, 2014; Yamhill Community Care Organization and Yamhill County Health and Human Services Activities and Insights, Oregon
Health Authority, 2014;
• 24,000 members
Public Health: Yamhill County
Our agency:
Environmental Health - restaurant inspection, water systems,
temporary events
Prevention & Health Promotion - tobacco, emergency
preparedness, accreditation
Clinical Preventative Services – reproductive health, STI,
Immunizations, travel
Communicable Disease – Epi/disease investigation (50
reportable), TB, dog bites
Home Visiting Nurse Programs – Maternity Case Management,
Cacoon
Vital Records – birth & death certificates
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My role (from 10,000 feet)
Clinician – foundational, relationship with populations I serve
Reproductive Health (RH)program manager – 2 Nurse Practitioners
(NP), state/national program compliance, EB/quality care, resource
management (over $100,000 medication budget)
Educator – patient (direct/indirect), department, community, state
Change agent – move system changes, communication/information
through the department
Forward-thinking, population & systems focused lens
Examples of RH population
health/quality care measures data
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efforts expand to other targeted venues in the future, please let us know when you return the form to us. You may add rows to this form as needed.
1) County or counties for which you are requesting CD supplies:
2) Number of condoms requested (lube will be provided too):
Select from drop down menu
3) CD sites (name of venues)
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2
3
4
5
6
7
8
9
10
11
12
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Total
Healthcare (HC)
or non-healthcare
(NHC) setting
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0
4) Indicators for 2013
Type of venue
drop down menu
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0
Mark "1" in the column(s) with the population(s) targeted at each CD site.
PLWH (persons
living with HIV)
MSM (men who
have sex with men)
0
0
Goal through 12/31/15
PWID (persons who inject drugs)
0
Result through
6/31/15
(6-month total)
Result through
12/31/15
(12-month total)
# of distribution locations
# of condoms distributed overall
# of condoms distributed to PLWH
# of condoms distributed to high-risk HIV negative persons
(MSM, PWID, partners of PLWH)
# of condoms distributed to general population
(should not exceed 30% of condoms)
5) Describe how condoms will be distributed (e.g., by HIV test or syringe services program staff, via bowls at targeted venues listed above).
6) Storage requirements: Condoms must be stored in a cool, dry place to prevent damage. Please ensure that staff and partnering businesses/agencies are aware of this
requirement and have an appropriate storage place. Additionally, staff should ensure that the expiration dates of condoms are checked at least once annually. Do you
agree to these requirements (Yes/No)?
7) Distribution requirements: Supplies may only be distributed free of charge. Money or donations may not be requested. Do you agree to this requirement (Yes/No)?
8) Contact person & information: Please provide contact information for the person who will coordinate condom distribution activities. Include a name, job title, email
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Populations & Microsystems
Adolescents
Clinical services
Low SES
Home visiting/Maternal Child Health
programs
Non-citizen
Spanish speaking
Public Health
Uninsured
Health & Human Services – Yamhill
County
Incarcerated
McMinnville High School
IVDU
County jail
MSM
Newberg clinic
Males
McMinnville vs. Newberg
Foster families
State reproductive health program
Homeless
County public health departments
clinician…
Every day open access clinic, culturally competent, clientclient-population centered
care
Reproductive Health – initiate birth control /method management/pregnancy
testing
STI screening, treatment (CT, genital wart, etc.), epi
Immunizations
Health records management
Lateral coordination of care – other HHS divisions, community providers, etc.
collaborate with Nurse Practitioner/Health Officer/PH Director – standing
orders, systems changes
operate offoff-site clinics providing services: local high school, clinic offices in
neighboring town, county jail
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outcomes manager…
Manage system changes – operationally (RH/STI program merger=increase
in Title X $)
EvidenceEvidence-based best practice to design care – effective use of LARCs = #1 in
state, adolescents
Yearly county RH data measure evidence-based metrics - support reducing
unintended pregnancies
RH program manager – yearly 3 SMART program goals to state -> used to
develop state goals
◦ Throughout the year updates and end-of-year reassessment
Track data from off-site clinics to adjust services e.g. report to school board # of student visits
OPRAHC - Oregon Preventive Reproductive Health Advisory Council
member - advisory group comprised of RH Program staff and both local and national
subject matter experts to develop a tiered set of standards for the provision of quality
reproductive health clinical services
Patient satisfaction survey
System assessment/improvements to facilitate multiple funding streams –
Ccare, Title X, Private ins
Birth control medication ordering – $100,000 budget
advocate…
Patient safety – development birth control patient information (health
literacy), medications
ACA access to insurance coverage – applications, enrollment assist
Educate (patients, colleagues, etc.) on state laws e.g. minors seeking birth
control/STI testing & treatment
Presentations to community partners – CASA
Meet with community partners to support vulnerable populations access to
services e.g GFU population, largest pediatric clinic regarding
developmentally appropriate adolescent sexual health
Develop training & foster culturally competent care in clinic – equal treatment
for all e.g. non-citizen, IVDU, gay man, adolescent, low-SES, homeless, ESL
ClientClient-centered care – meet them where they are
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information manager…
PowerPoint presentations in the community & in-house training
Email, Outlook, spreadsheets (inventory, data collection, etc.), H:/
Raintree scheduling system - custom reports, data collection,
collection efficient
clinic scheduling
Member of new EMR implementation team
Access and distribute EBP articles,
articles changes in national quality care
guidelines (CDC MEC), county data & epi statistics
On-line medication ordering
Maintain standing order/protocols for RH program operations
Liaison to program operation/management with state RH program staff
systems analyst/risk
anticipator…
Assess microsystems – high school, city, clinic RN team vs. home visiting RN
team, each PH program (CD, IMMS, etc.)
contraceptive/RH supplies purchasing & inventory management
Member of PH Quality Improvement/Performance Management team
(referral system from jail)
confidentiality – assurance,
assurance insurance
client-centered riskrisk-reduction care/communication e.g. contraception, sexual
health, homeless
research/evaluate in consultation with NP/HO new medications – safety,
efficacy, &
implementation, standing order e.g. Ella, Skyla
facilitate proper state board of pharmacy license and adherence to
regulations (e.g. medication labeling, RX dispensing laws)
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educator…
therapeutic use of self patient education – “relational nursing”
families, parents, patients, peers, partners
high school – freshman seminar, health classes (~500 students/year) RH
community groups – CASA, parenting class, teachers, pediatricians practice
Other HHS divisions – Family & Youth (foster youth population)
public health inin-services for Yamhill County PH colleagues – e.g. emergency
contraception
mentor for new RH staff at other public health departments in state as
referred by state nursing
consultant
Adjunct faculty at Linfield College – Human Sexuality
Site preceptor for 4 senior BSN students a year for community health rotation
– George Fox Univ.
team member…
WalkWalk-in RN rotation
CrossCross-trained and practice in other PH programs (RH, CD, STI, IMMS,
home visiting)
Train new employees, colleagues
Member of interdisciplinary Newberg services team (FQHC, county
behavioral health & chemical dependency)
Lateral patient care coordination with local providers (hospitals, FQHC,
PCPs, pediatricians)
Triage STI calls and schedule appropriately
PH summer retreat planning team member
Clinic communicator
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member of a profession…
Member of professional organizations – OR Public Health Assoc., CNL
Assoc., county union
Attend annual statewide RH coordinators meeting
Continuing education – webinars, conference calls, in-services, journal
articles
Member of statewide RH committee
Precept senior BSN students
Explore new nursing opportunities/programs – behavioral health, foster
care youth
The future…
Join nursing services across public health &
behavioral health
New position:
position Nursing Supervisor
CCO, PH collaborative work incentive metrics,
metrics
new metrics
“safety-net” services & innovation
?
Thank you
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